Monday, August 31, 2015

Annual Meeting Day 3, August 23, 2015



We always have attrition by Sunday morning at these meetings. We walk in to find half as many tables and chairs as were in the room for Saturday. Do those who come for the final morning sometimes find the keys to a brand new car taped under their seats? I’m not saying. But here’s what we learned:

Daniel Krowchuk, MD
Office Dermatology, What’s Your Diagnosis?

  • Lichen striatus. Lichen means “flat.” Flat, linear = lichen striatus.
  • Usually affects young children, unknown cause. Starts on an extremity proximally, extends distally.
  • People try steroids, not clear that they’re effective
  • If it reaches a digit, you can see nail dystrophy
  • On the trunk it forms a curvilinear pattern, following Blaschko’s Lines
  • Lichen Nitidus. Also flat-topped papules, but brighter, shinier than lichen striatus. Often grouped, often appear at areas of trauma (Koebner phenomenon). No real treatment.
  • Lichen planus: Pruritic, purple, polygonal, planar, papules. Often involve male genitalia.
  • May see striae as well.
  • Challenging to treat
  • Lice: finding the little buggers can be challenging. They move quickly, avoid light, blend in to the hair.
  • Nits (eggs) are useful but of limited value. Viable eggs blend into the hair color, look white once the egg has hatched. If you see a white nit > 1 cm from the scalp, almost certainly dead, not active infestation.
  • Permethrin remains first line therapy. Resistance does exist to permethrin and pyrethrins
  • Treatment failure is sometimes due to inadequate treatment. No conditioning shampoo! Leave on 10 mins! DO treat again in 7 to 10 days! Consider another follow up treatment at 13-15 days.
  • Second line: ivermectin, spinosad, benzyl alcohol covered by Medicaid. Dimethicone (Lice MD) is least expensive at $14. Ulesfia is next at $61, but if you have long hair you’ll need more.
  • Services will come to your home and comb out the hair with a topical non-pesticide mousse or heat.
  • Louse Buster is 98% effective, Air AllĂ© is similar, even more effective (99%).
  • Eruptive hypomelanosis: Spotty, hypopigmented macules on the extremities following a viral URI by about 10 days, on the extremities.
  • Pityriasis alba are ill defined, persistent. Tinea versicolor is better-defined.
  • Think about measles with maculopapular rash in the company of fever, conjunctivitis, cough, URI symptoms!
  • Remember: incubation 8-12 days, prodrome 3-5 days with low fever, cough, coryza, conjunctivitis. Koplik spots: gray-white dots with surrounding erythema start next to the lower molars, then spread. Resolve by day 2-3 of the rash, evanescent, easy to miss
  • Rash starts as faint macules along the neck,hairline, then spreads to face, trunk, arms, then works its way to the feet, fading at the face/neck.
  • Give MMR vaccine to anyone over 6 months leaving the country. If over 12 months, give 2 doses separated by 28 days prior to travel.
  • Measles leads to pneumonia in 1/2, encephalitis 1/1000, death 1/3000.
  • Chicken pox: lesions in various stages of evolution! Vesicles, papules, crusts.
  • Contagious before the rash appears. Incubation 14-16 days. Once crusts are formed, no longer contagious.
  • Consider therapy for kids older than age 12, chronic skin or asthma, long-term aspirin therapy, inhaled steroid therapy, secondary cases in the same household.
  • Occasionally varicella-zoster Ig can be helpful.
  • Hand-foot-mouth: Low-grade fever, sores in mouth, vesicles on the palm/soles with red rings.
  • Coxsackie A-16, but other viruses can do this, too. Atypical form is Coxsackie A-6 in most cases. Usually more widespread, can look like Gianotti-Crosti or eczema herpeticum. More commonly involves the face. Can develop large bulla. Becoming more common.
  • Eczema herpeticum: vesicles which rupture and leave small, round, punch-like ulcers.
  • Gianotti-Crosti: extensor surface papules, also on the face, tend to be large, accompany vaccines, some viral infections.
  • Patches of dry, scaling skin on the posterior thighs, seasonal (fall, not summer). Metal allergy from rivets on school chairs! (Gotta see the chair photo for the full experience)
  • Poison ivy: most common form of contact dermatitis. Often with linear distribution at least in some areas. Look for facial patches: wiping the face with a sleeve that has the oil on it.
  • Nickel dermatitis is subacute, chronic. Look at earring posts, eyeglass frames as well.
  • Contact dermatitis can occur now with wet wipes, car seat covers (look where the legs, elbows touch the car seat), toilet seats (polyurethane), shin guards, underwire or foam bras.
  • Tinea capitis can look seborrheic, with widespread scale.
  • Tinea (pityriasis) amiantacea: thick scale that entraps hairs, may get some hair loss. Treat with salicylic acid shampoo or phenol & saline shampoo (Baker’s P&S). Leave on 15-20 minutes.
  • Cafe au lait macules. Not just associated with NF type 1. Also Legius syndrome, Familial CALM, McCune-Albright, Watson, and Bloom syndrome. About 75% of kids with 6 or more macules with have neurofibromatosis type 1.
  • Need 6 or more cafe au lait spots, may have axillary or inguinal freckling, >2 Lisch nodules (ophthalmology), 2 or more neurofibromas or at least 1 plexiform neurofibroma, characteristic osseous lesion, 1st degree relative with NF1.

Emmanuel Walter, MD
An Update on Vaccine-Preventable Diseases

  • Historical: elimination or vast decreases in smallpox, diphtheria, pertussis (less so), tetanus, polio, measles, mumps, rubella, haemophilus B influenza, CRS.
  • Now also with marked decreases in HAV, HBV, pneumococcal disease, rotavirus, varicella
  • HPV is the most common sexually transmitted infection in the US, with 7 million persons infected, 14 million new infections annually.
  • HPV causes nearly all cases of cervical cancer, 12,595 cases per year and nearly 4000 deaths per year.
  • About 40% of female college students are infected within 2 years of first sexual intercourse
  • Not all people who get infected develop cervical cancer. Can develop CIN 1, 2, or 3. The longer you’re infected without clearing, the more likely you are to develop cervical cancer.
  • There are over 120 different types of HPV. 80 types are cutaneous, 40 types are mucosal. Many are low-risk. Some are oncogenic, most famously 16 and 18.
  • Females cancers: cervical, vaginal, vulvar, ano-rectal, OP.
  • Males cancers: penile, ano-rectal, oropharyngeal cancers (over 11,000 cases per year)
  • About 15% of female cancers were due to 31, 33, 45, 52, and 58. In males, these strains account for 4% of cancers, with types 16 and 18 causing about 63% of cancers.
  • New vaccine will prevent more female than male cancers.
  • All 3 types of vaccine are highly effective against warts, precancerous lesions, 98% to 100% for females.
  • Approval for HPV 4 is age 9-26 years. HPV9 is 9-26 years for females, 9-15 years for males per FDA.
  • Schedule: three vaccines at 0, 1-2 months, 6 months later, starting at age 11. May be given as young as age 9.
  • Late dosing does not appear to affect antibody levels. Give it when you can, three years in a row if you must.
  • Good reason to start at age 11-12, because it can take years to complete the vaccines.
  • HPV 9 versus 4: may see more swelling and erythema among females, not among males.
  • Alternate dosing schedules, fewer doses are being studied, but still pending.
  • Neisseria meningitidis: leading cause of bacterial meningitis and sepsis in the US.
  • Incubation 2-10 days. Meningitis, pneumonia, arthritis, otitis media, epiglottitis, meningococcemia. Fatality rate is 10-15% overall, 40% from meningococcemia.
  • Respiratory droplet or direct contact transmission.
  • Risk factors: terminal complement deficiency, asplenia, Solaris treatment (eculizumab), genetic factors.
  • Environmental risk factors: household crowding, smoking, prior viral infection, occupational exposure.
  • Incidence is dropping rapidly over the last 2 decades, with decline starting prior to vaccine
  • Serogroups B, C, Y, W-135 cause most infections. Serogroup B is a big problem for infants, again for older children/teens, adults.
  • There are 3 meningococcal conjugate vaccines, with Menactra and Menveo being most used, but MnHibrix is also available for children ages 6 weeks to 18 months.
  • The group B polysaccharide is a potential auto-antigen expressed by host tissues and is a poor immunogen, poses a challenge to developing an effective vaccine against serogroup B.
  • Serogroup B outbreaks have affected 3 universities in the US, ed to fast-track approval of Bexsero, Trumemba in the US. These are protein-based, not polysaccharide-based, ages 10-25 years, dosing schedules differ.
  • The two vaccines named above are recommended for persons with increased risk, including microbiologists or outbreak situations.
  • No routine recommendation, but individuals ages 16-23 may choose to have the vaccine, with preferred age of 16-18 years.
  • Why not routine? The disease rate has declined, about 60-80 cases per year of which about half could be prevented with universal vaccination. If we just vaccinated college kids, we could prevent around 10 deaths a year.
  • Post-vaccine syncope in adolescents is among the more common issues reported to VAERS. Still not common. AAP recommends 15 minutes of observation after adolescent vaccines.
  • Drinking water about 15 minutes before blood draws seems to help, so Duke is looking at a pre-hydration intervention to decrease syncope.
  • Influenza vaccination. Each season brings new challenges.
  • In 2014 we recommended live vaccine over IM. As it turned out, the vaccine ended up being less stable at higher shipping temperatures due to a hemagglutinin component. That year there was major drift to H3N2, and it was a pretty lousy year for protection.
  • For 2015 the H1N1 strain has been switched out, with a more stable hemagglutinin protein, hopefully will be more effective. Currently no preference for live attenuated versus inactivated.
  • Again, no LAIV if child has wheezed in the last 12 months if ages 2-4 years, consider asthma as a precaution in general. However, studies appear to show that LAIV is safe in asthma, still not clear if it’s okay with moderate to severe persistent asthma.
  • Two strains are being switched this year.
  • One dose if child has had 2 or more prior doses, 2 doses if not.
  • Future trends: look for DTaP, IPV, HepB, Hib combo vaccine, adjuvanted flu vaccine, RSV vaccine, parainfluenza vaccine. Pregnant women may get RSV and Group B strep vaccines.
  • Safety questions? Can email CISAeval at cdc dot gov.
  • 4 doses of polio to get into Kindergarten now, 2 doses of varicella. Tdap, meningococcal vaccines to get into 6th grade.

Susan Mims, MD, MPH, Mary Ellen Wright, PhD, APRN, CPNP, Paul Furigay, MD, Tammy Cody, LCSW
Handle With Care: A Family-Centered Approach to Neonatal Abstinence Syndrome


  • Substance-exposed Newborn (SEN), Neonatal Abstinence Syndrome (NAS)
  • Clinical diagnosis based on neurologic excitability. Can withdraw from many substances, but opiates are the most predictable in terms of causing symptoms.
  • Interventions can be both pharmacologic and non-pharmacologic.
  • Babies are sensitive to light and sound.
  • Skin-to-skin, upper body swaddling, pacifiers can be helpful
  • Challenges: identifying these babies — women may not disclose due to non-supportive environment for disclosure.
  • CCNC provides a good screening tool for OB’s to use at intake, but many OB’s don’t repeat these questions every trimester as advised. Ask again at admission to L&D.
  • Some states/hospitals are performing universal toxicology screening. Cord blood can be used, may reflect a longer time frame than meconium, offers more substances, can be a shorter turn-around time.
  • Newest drugs of abuse may not be included on toxicology screens
  • Evaluation challenges: assessment tools may be difficult to standardize. Timing of withdrawal symptoms can vary by substance and infant.
  • Treatment challenges: lack of maternal addiction programs, community services available to mothers in the community.
  • Mission Children’s has seen a 400% increase in NAS since 2010.
  • Mission formed a community collaborative to address the problem in western NC.
  • Helpful to involve child life specialist, pathology lab representative.
  • This is a community-wide problem, requires an approach that extends to prevention, care coordination, not just the newborn nursery
  • Moms were really worried about being judged by the care team, make them less likely to disclose.
  • Moms felt that learning how to monitor and comfort baby (snuggling) is very helpful.
  • Moms would like to do peer education for other mothers.
  • Weaning protocol: 10% wean of dose every week over 2 months. Stop at <0.03 mg/kg/day.
  • Short-acting opioids, monitor for 48-72 hours. Longer-acting opioids require days of inpatient monitoring.
  • Criteria for discharge: no change in baseline over 2-5 days, Finnegan scores under 8 for 48 hours. DSS must be involved if drugs are illicit, MOC not in treatment at admission.
  • Follow up 2x/week for 2 weeks, then weekly for 7 weeks with weight check and withdrawal assessment.
  • Provide a 1-month Rx for methadone at discharge dose.
  • Weaning protocol provided in discharge paperwork to outpatient MD.
  • Should be off phenobarbital, clonidine prior to discharge.
  • Discharge education includes extensive breastfeeding support, education on soothing and caring for infant withdrawing from opioids, home health referral.
  • Babies also get early intervention referral, follow up at neonatal toddler follow up clinic at Mission.
  • Several counties in the Mission Children’s service area offered no or very limited home health services. Mission worked to on-board agencies to improve access to home health for these mothers.
  • Trans-disciplinary team: synergy of the whole team moves the process forward, regardless of which team member brings his/her contribution to the process.
  • Mission is now working on a transition center for moms/babies who meet discharge criteria but do not have adequate medical/social support in their communities.
  • Writing a great referral to social services in the community does not guarantee mothers will receive services. Dropout rate is very high.
  • Transition center allows for education, assessment, coordination of community agencies for transition to home, breastfeeding consultation.

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